Henry Williams

Henry Williams

1. Medical Dx

   • Primary Medical Dx
     • COPD, Asthma, Cardiovascular Disease, Diabetes Mellitus
   • Other Medical Dx
     • Healing Loss (has aids)

2. Current Meds

   • Albuterol- 2 puffs, PRN for SOB Montelukast- 10mg PO, every evening to prevent asthma attacks/inflammation Prednisone- 40mg PO Q24 X10 days for inflammation Lisinopril- 12.5mg PO Q24 to decrease BP, Metoprolol Succinate-50mg PO Q24 to decrease BP Rosuvastatin Calcium 20mg PO Q24, every evening to treat high cholesterol Aspirin- 81mg PO Q24 for blood thinner and inflammation, Fluticasone Propionate and Salmetrol Inhalation 250/50mg inhaled

3. 69 yr old male, wt: 193 lbs

4. Vitals

   • BP: 135/88 from 160/92, HR: 112 from 110, RR: 26 from 30, O2: 88 from 82, Temp: 98.4 from 98.6

5. Labs

   • Blood Glucose: 199 from 109, WBC: 11.8 (5-10), HGB: 10 (13.5-17.5) HCT: 40 (41-53)
     • Arteriol Blood Gases in normal range

6. 1. Ineffective breathing pattern r/t SOB/Anxiety AEB RR of 26 and O2 sat of 88%

   • Goal: Pt will have a lowered respiratory rate of 22 by the end of shift
     • 1. Pt's respiratory VS and cues will be monitored every 2 hours 2. Keep pt in upright position to open lungs 3. Ensure prescribed O2 is given at correct rate and reached to 90 and above 4. Respiratory meds will be take on time 5. Albuterol inhaler will be in reach of Pt 6. Pt will do breathing exercises every hour 7. Offer Pt water every hour 8. Teach pt positions to help with increased ease of breathing 9. Assist Pt to perform ADL's as needed or monitor 10. Make sure call light is in reach
       • Potential Labs/Assessments: What is causing the anxiety, do neurological check

7. 2. Activity Intolerance r/t imbalance between O2 supply/demand AEB RR of 26, O2 88%, and HR 112

   • Goal: Pt will demonstrate increased tolerance to activity by end of discharge
     • 1. Pt's VS wil be monitored every 2 hours and after ambulating 2. Ensure prescribed oxygen is given to maintain 90 and above 3. Pt's respiratory meds will be taken on time 4 Pt will remain in upright position as often as possible 5. Bed commode will be at pt's bedside 6. Daily assessment for improvement so activity can be gradually progressed 7. Provide ROM excercises within Pt limits 8. If VS or cues worsen, stop activity immediately (Respiratory*) 9. Have Pt do breathing exercises every hour 10. Maintain nutrients
       • Potential Labs/Assessments: Pt's ADLs and what they need assistance with, their baseline in activity, what is making their intolerance better/worse- verify that it is due to respiratory, not cardiac- any chest pain, see if he is eating/getting nutrition

8. Special Orders/Diet

   • Diet: Low Fat
   • Oxygen: Nasal Cannula at 2L/min (if O2 less than 60, O2 to keep 90 and above)
   • Bedrest, bathroom with assistance
   • Lactaded Ringer, 50mL/hr

9. 3. Risk for unstable blood glucose r/t immobility and anxiety

   • Goal: Pt's glucose levels will be maintained at baseline near 109 until discharge
     • Interventions: 1. Obtain order for insulin from Dr (not in sheet) and be ready to give PRN 2. Obtain blood glucose levels before and after meals and/or snacks 3. Monitor Pt for hyperglycemia (increased urination/thirst). 4. Monitor Pt for hyperglycemia (confusion, anxiety, heart palpitations) 5. Use teach back method to teach pt symptoms of hyper/hypoglycemia and when to call for help 6. Consult with dietician on carb count diet 7. Make sure client has call light in reach 8. Have patient do hand and feet movements while on bed rest to improve circulation 9. Be aware of any new or current meds that can alter blood glucose 10. Make sure Pt is eating a balanced diet
       • Potential Labs/Assessments: Pt's glucose levels, Pt's Baseline for glucose, if they are aware of their disease/understand how to manage it

10. Master Intervention List

    • 1. Make sure pt has had meds, 60 sec scan- focus on safety of O2, drains, side rails up, respiratory cues, make sure bed is upright and inhaler/call light is in reach with bed rails up 2. VS/cues taken every 2 hours, including glucose levels initially, as well as before and after meals. 3. Head to toe assessment will focus on A&O's, respiratory and circulation, checked for bleeding and assess for malnutrition 4. Offer the patient water 5. Keep patient's bed in upright position. 6. Provide breathing exercises- try to breath in slow/exhale through pursed lips and monitor for distress 7. Test and assess for ROM 8. Make sure commode and pt belongings are in place .9. Ask patient if they need to use the commode 10.. Routinely assess patient's ability to ambulate and stop is any distress occurs. 11.. Assist patient as needed to ambulate 12.. Take VS and assess for signs for distress before and after pt ambulate.
      • 13.. Provide ROM excercises/turn every two hours/passive exercise at patients limit 14. Monitor Pt for hyperglycemia (increased urination/thirst). 15. Monitor Pt for hyperglycemia (confusion, anxiety, heart palpitations) 16. Consult with dietitian to make sure Pt is on proper diet 17. Assess patient for malnutrition signs 18. Make sure patient is eating 18. patient will demonstrate breathing exercises every hour on their own by endow shift 19. Teach patient the signs of high or low blood sugar and provides teach back method 20. Teach Pt positions to help with eased breathing 21. Patient will sip water every 2-3 hours on their own by the end of shift 22. Patient will keep call light in place 23. Belt will be used for safety when ambulating patient if needed 24. Patient will understand own limits and use the call light